The Health and Adult Social Care Scrutiny Commission was scheduled to review how the local system supports residents following hospital discharge, including access to reablement and post-hospital care. The Commission was also set to consider early learning from the Barnsley Street Community Mental Health Pilot and its implications for community-based mental health provision.

Close to Home - Part 2: Hospital Discharge and Reablement

The Commission was scheduled to review the local system's support for residents following hospital discharge, focusing on reablement and post-hospital care. This was the second part of a scrutiny series titled Close to Home, which aims to examine how health and care partners support residents to receive effective care closer to home. The session was intended to cover current system pressures and responsibilities within acute care, including emergency attendances, admission trends, and delayed discharges. Evidence was to be heard from Newham Hospital (Barts Health NHS Trust), East London NHS Foundation Trust (ELFT), NHS North East London Integrated Care Board (ICB), and Healthwatch Newham. A supplementary submission from the Council's Adults and Health Directorate was also to be considered.

The report from ELFT highlighted their Community Health Services' role in providing care closer to home, preventing hospital admissions through multi-disciplinary teams, and offering rehabilitation input for up to six weeks. However, it noted capacity challenges due to a national shortage of therapists and increasing demand for district nursing services. The report also detailed the Integrated Discharge Hub's function in supporting the Discharge to Assess model and coordinating step-down care. It was noted that while patient experience of care at Fothergill Ward was high, audits indicated that patients often stayed longer than clinically necessary due to complex discharge reasons, such as delays in securing placements or care packages.

The submission from the London Borough of Newham's Adults and Health Directorate outlined the statutory framework for hospital discharge under the Care Act 2014 and detailed local arrangements for multi-disciplinary team assessments and the Integrated Discharge Hub. It confirmed Newham's operation of the NHS's Discharge to Assess (D2A) model, with pathways for returning home with support, short-term rehabilitation, or long-term care. The Directorate highlighted that Newham often has one of the lowest rates of acute bed days lost to delay in London. The report also detailed short-term investments for 2025/26, including funding for the Integrated Discharge Hub, mental health intermediate care, and housing support roles. It also discussed the impact of deconditioning during hospital stays and identified barriers to integration, such as differing IT systems and short-term, inconsistent hospital discharge funding.

Newham Hospital's contribution focused on system-wide evidence, noting that repeat admissions are concentrated in older adults and those with frailty, but also include younger adults with long-term conditions and socially disadvantaged groups. They identified insufficient step-down bed capacity as a bottleneck, leading to patients being placed outside the borough. The hospital's perspective on the Fothergill Ward audit suggested that while the ward served a purpose for end-of-life care and patients with complex discharge needs, its current use was not always optimal, and many patients could receive more appropriate care in their own homes or community settings. They highlighted challenges with housing adaptations, cleaning, and decluttering, as well as limited in-borough capacity for nursing and residential beds.

NHS North East London's submission provided an overview of neighbourhood priorities, including work on diabetes and cardiovascular disease, and a proactive approach to identifying and supporting individuals with complex needs. They noted that while direct benchmarking between boroughs for community services data was difficult, North East London was performing well against urgent community response targets.

Age UK East London's submission detailed their involvement in hospital discharge and reablement, providing home assessments, welfare checks, and four weeks of post-discharge support. They highlighted their distinctive role in building trust, offering flexibility, and connecting individuals with wider community services. Opportunities for expansion included greater strategic involvement, service expansion, and a potential presence in the Emergency Department. Challenges identified included referral awareness, patient updates, and the use of blocked numbers for contact.

One Newham & Sustainable Newham's submission outlined the role of Voluntary, Community and Faith Sector (VCFS) organisations in supporting discharge and reablement, including Age UK East London's Home & Settle service and Community Connectors. They emphasised the VCFS's distinctive role in cultural competence, flexibility, and holistic support, and identified opportunities for expansion through formal inclusion in discharge planning and commissioning of tailored reablement programmes. Challenges included delayed discharges, lack of follow-up, and barriers to accessing culturally appropriate services.

Healthwatch Newham's contribution summarised findings from their 2022 Hospital Discharge Project and subsequent observations. While improvements in communication and carer inclusion were noted, persistent operational issues such as pharmacy delays, transport waits, and inconsistent reablement referrals remained challenges. They recommended introducing discharge-specific feedback mechanisms, expanding qualitative monitoring, and addressing operational delays.

Barnsley Street Neighbourhood Mental Health Centre - Pilot Update

The Commission was scheduled to receive an update on the Barnsley Street 24/7 Neighbourhood Mental Health Pilot. This pilot, one of six across England, aims to provide walk-in community mental health facilities based on the 'Trieste' model, which is believed to have reduced the need for acute beds in Italy. The report was expected to outline the pilot's launch timeline, publicity efforts, and initial data on access and user profiles. It was also to cover how feedback from service users and stakeholders is being captured and to set out key learning, challenges, and potential future plans for the model, including its relevance for Newham. A site visit report from the Barnsley Street Centre in Tower Hamlets was also provided, detailing the facility's design, governance, and initial performance impact, including a reduction in length of stay and new admissions.

Work Programme

The Commission was scheduled to review and confirm its work programme for the upcoming year. This included a standing item for updates on emerging issues, a review of the CQC assurance process for Adult Social Care, and substantive items such as the Close to Home series, an assessment of alcohol harm and inequalities, and a review of the Barnsley Street Neighbourhood Mental Health Centre pilot. The work programme also outlined future topics for scrutiny, including the CQC's full inspection of Adult Social Care, the Close to Home series focusing on prevention and isolation, an Adult Safeguarding Review, and potential discussions on maternity services and oral health.